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Ann Thorac Surg 2000;69:326-329
© 2000 The Society of Thoracic Surgeons
a Department of Surgery and Institute of Human Values in Health Care, Medical University of South Carolina, Charleston, South Carolina, USA
b Division of Legislative Counsel, American Medical Association, Washington, DC, USA
Address reprint requests to Dr Sade, Institute of Human Values in Health Care, Medical University of South Carolina, 96 Jonathan Lucas St, Suite 409, Charleston, SC 29425
e-mail: sader{at}musc.edu
Presented at the Postgraduate course of the Forty-sixth Annual Meeting of the Southern Thoracic Surgical Association, San Juan, Puerto Rico, Nov 4–6, 1999.
Abstract
Background. Discussion of ethical issues occurs much less often in the surgical than in the medical literature. The reasons for this "ethics gap" are unknown.
Methods. Our clinical faculty ranked the ethical and legal acceptability of four treatment options in two cases of surrogate decision making. Only one option in each case was ethically and legally unacceptable (treating despite objection by the surrogate decision maker).
Results. Surprisingly often, faculty mistakenly believed the ethically unacceptable option to be acceptable, and the legally unacceptable option to be acceptable. Surgeons were not ethically different from other physicians. Surgeons (19 of 31, 62%), however, were significantly (p < 0.05) more likely than internists (18 of 51, 35%) or pediatricians (4 of 18, 22%) to believe, mistakenly, that operating on the baby without parental consent was legally acceptable.
Conclusions. This pilot study did not identify why the surgical literature contains a relative dearth of ethics discussion. Broader investigations are needed, because it is important that we understand the reasons for the gap. Surgeons’ strong ethic of personal responsibility for patients’ welfare should be transmitted to young trainees, a goal best achieved by discussing and writing about ethics. Moreover, our legal data suggest that a gap may also exist between surgeons and other physicians in understanding health law.
Over the last few decades, new technologies have made possible levels of life support that were previously unavailable. Renal dialysis, organ transplantation, ventilators for respiratory support, and cardiac support devices have contributed to longer and better quality of survival than was previously possible for many patients suffering from vital organ failure. For many others, however, these technologies have led to survival with a poor quality of life, particularly in patients with brain injury or inadequacy of other major organs. Quandaries involving the way in which decisions are made led to a growing emphasis on the notion of autonomy: namely, the moral and legal right of patients to make decisions regarding their own bodies and their own healthcare. The idea of informed consent and informed refusal of care is relatively new, having grown from case law early in this century, then from the dialogue between ethicists, policymakers, physicians, and others over the past few decades.
Clinicians have also paid increasing attention in recent years to many other ethical issues, such as privacy and confidentially, truth telling and disclosure, and surrogate decision making. This attention has been reflected in medical periodicals and books, but the extent to which such discussions take place has varied among medical specialities. Surgeons in particular have been singled out as participating in discussion of ethical issues less frequently than other specialists.
A recent survey compared the surgical literature with the medical literature over a 1-year period, the 1992 publication year [1]. The authors carried out a detailed Medline search using key words related to ethics and bioethics in 12 surgical and 15 medical journals. The authors found that discussions of bioethical issues occurred much less frequently in the surgical literature than in the medical literature. Of 2,645 articles identified in 12 surgical journals, 17 (0.6%) contained substantive discussion of an ethical issue. Of 11,239 articles identified in 15 medical journals, 307 (2.7%) had ethics commentary. Thus, the medical literature contained over four times the frequency of ethics discussions than the surgical literature. This has been referred to as the "ethics gap" in surgery.
The reasons for the ethics gap are unclear, but several possibilities have been suggested [1]. (1) Surgeons may ascribe less importance to ethical considerations than internists do, so talk about them less. (2) The traditional beneficence model of medical ethics (doing what is best for the patient), a fundamental surgical principle, sometimes conflicts with the contemporary autonomy model (patient self-determination, which may include refusing medically indicated treatment). For this reason, surgeons may feel alienated from contemporary bioethical discourse [1, 2]. (3) There is evidence that surgeons are more authoritarian than other physicians, perhaps because of their professional training and the nature of surgical practice [3, 4]. If this is true, surgeons may be more likely than other physicians to make paternalistic decisions and fail to recognize ethical problems when they appear. (4) Ethical principles may be so deeply ingrained in surgeons through training and practice that discussion of the principles may seem redundant [5]. One surgical educator has explained the ethics gap in this way: "The difference between surgeons and internists is that surgeons practice ethics, while internists mainly talk about it" (Griffen WO, personal communication).
We have observed that a type of case that seemed particularly subject to potential conflict and to differing perceptions among specialties was patient incapacity requiring surrogate decision making. We therefore undertook a small pilot study using two cases of this type to try to elucidate reasons for the ethics gap, as well as to investigate physicians’ understanding of their legal obligations in such circumstances.
Material and methods
We surveyed our academic medical center faculty by soliciting their views of ethical and legal options available to the physician in each of two cases of surrogate decision making. The standard for ethical acceptability was derived from published guidelines for surrogate decision making from six medical organizations, only one of which was surgical [6–11].
Finding a standard for legal acceptability was not as straightforward, because the outcome for any particular legal challenge is not predictable. Rather than labeling the options as legal or illegal, we used the terms "acceptable-unacceptable" or "prudent-imprudent," based on whether a reasonable attorney would be likely to advise that a particular option had a greater or lesser likelihood of being upheld in a court of law. We solicited legal opinion regarding which of the options would be legally prudent or imprudent on grounds of liability risk.
Case 1 was that of a young woman suffering from severe brain injury with potential for only minimal recovery at best, whose parents wanted to withdraw feeding, based on comments made by their daughter in the past. Case 2 was that of a newborn infant with hypoplastic left heart syndrome and Down syndrome, whose parents asked that prostaglandin be discontinued.
Four options for responses by the physician were provided for each case. Three were ethically acceptable options in both cases: accede to the parents’ wishes, withdraw from the case and transfer the care of the patient to another physician, and seek a court order to continue life support. The fourth option was the only one that was ethically unacceptable; continue treatment despite objection by the surrogate decision maker. The published opinions or policies regarding surrogate decision making of nearly all six organizations explicitly supported this classification of options; none expressed an opinion at variance with it.
The legal status of the four options, according to our legal counsel, was exactly parallel to their ethical acceptability: the first three options were deemed to be legally prudent, while the fourth was legally imprudent.
The survey requested that each option be rated as either ethically acceptable or unacceptable, and that the options be ranked in order of ethical preferability. It also requested that each option be rated as either legally acceptable or unacceptable, and that the options be ranked in order of legal preferability.
In case 2, we also asked whether the respondent would have changed their ratings or rankings of the options if the child did not have Down syndrome.
We searched our data for evidence to support the several possible explanations for the ethics gap cited above. If surgeons ascribe less importance to ethical considerations than internists do, or feel alienated from contemporary biomedical discourse, they perhaps would have not responded to the survey as frequently as others, so we measured the response rate to the survey. If surgeons fail to recognize ethical problems because they are more paternalistic than other physicians, then their responses should reflect more authoritarian attitudes than those of other physicians. We, therefore, combined two options as authoritarian (willingness to treat over parents’ objections, and seeking a court order to override the parents) and two options as nonauthoritarian (willingness to accept parents’ decision to withdraw treatment, or transferring the patient to another physician who was willing to withdraw treatment). We then compared the most highly ranked options of surgeons with those of other physicians to determine their relative levels of authoritarian and nonauthoritarian choices. Finally, if ethical principles are so deeply ingrained in surgeons that their discussion seems redundant, there should be more agreement in choice of options among surgeons than among other specialty groups. We measured this by recording the proportion of physicians in each specialty who agreed on the acceptability of each ethical option.
Response rates among specialties were compared using the Pearson 
2 test. Univariate and multivariate analyses of ratings of ethical and legal options were done by specialty (surgery, medicine, pediatrics), seniority (junior = 20 or fewer years vs senior = more than 20 years after medical school graduation), and gender (female vs male). The univariate analytic method was the Pearson 2 test, using Yates correction factor when appropriate. Logistic regression was used to perform the multivariate analyses. All analyses were carried out with BMDP Statistical Software, Release 7 (SPSS, Inc, Chicago, IL).
Results
The survey was mailed to 407 faculty physicians, and 133 (33%) responded. Responses were grouped into surgery (including all surgical specialties), internal medicine (including all medical specialties), pediatrics, and others (eg, pathologists, radiologists). For interspecialty comparisons, only the surgeons, internists, and pediatricians had sufficient numbers for statistical comparison. The response rates for those groups were: surgeons, 31 of 74 (42%); pediatricians, 18 of 44 (41%); and internists, 51 of 173 (29%); surgeons’ response rate was significantly higher than that of internists (p < 0.05).
Ethical responses
Many faculty members mistakenly believed it to be ethically acceptable to override the wishes of the parents (case 1, 88 of 132, 67%; case 2, 57 of 132, 42%). That ethically unacceptable option was ranked as the first choice among all options by 33 of 133 (26%) of faculty members. Every commentator on ethical standards for treatment of disabled individuals has held that disability, including mental disability, should not be the sole grounds for making treatment withdrawal decisions. Nevertheless, 44 of 115 (38%) faculty members would have made a different treatment decision if Down syndrome had not been present in case 2.
When we compared the specialties for their ethical choices, surgeons did not either rate or rank any ethical option differently from either internists or pediatricians.
Authoritarian responses were ranked the first choice more often by pediatricians (9 of 18, 50%) than by surgeons (3 of 28, 11%) or internists (11 of 51, 22%) (p < 0.05). The survey revealed uniformity of ethical views among the three groups: no differences were detected in the proportion of identical ratings of options by surgeons (76%), internists (74%), and pediatricians (71%).
Legal responses
Among the general faculty, the only legally imprudent response, to continue treatment over the objections of the parents, was mistakenly believed to be legally prudent in case 1 by 73% of our faculty, and, in case 2, by 39%. It is legally unacceptable to treat children with Down syndrome differently from other children, yet 44 of 115 (38%) of our faculty would have treated case 2 differently if Down syndrome had not been present; there were no differences among specialities.
Several differences appeared when comparing the legal responses of specialty groups. Pediatricians (61%) were less likely than surgeons (84%) and internists (85%) to recognize that it was legally acceptable to discontinue feeding at the parents’ request in case 1 (p < 0.05). Pediatricians (78%) were also less likely than surgeons (92%) and internists (98%) to recognize in case 2 that challenging the parents in court was legally acceptable (p < 0.05). Surgeons (19 of 31, 62%), however, were more likely than internists (18 of 51, 35%) or pediatricians (4 of 18, 22%) to believe, mistakenly, that operating on the baby in case 2 without parental consent was legally acceptable (p < 0.05).
Age and gender
Univariate and multivariate analyses showed no difference in any ethical or legal measure by gender (male = 98, female = 25), and only two differences by seniority. By multivariate analysis, senior faculty members were more likely than junior faculty members to mistakenly rate discontinuing feeding in case 1 as ethically unacceptable (10 of 51 [20%] vs 9 of 82 [11%], respectively, p < 0.05). Senior faculty members were also ethically more authoritarian than junior faculty members (23 of 51 [45%] vs 21 of 82 [26%] in case 1, and 17 of 51 [34%] vs 14 of 82 [17%] in case 2, respectively, both p < 0.05).
Comment
The surgical literature contains fewer discussions of ethical issues than the medical literature. Moreover, in searching for official positions taken by a wide range of medical organizations on surrogate decision making, we found only one by a surgical society, the American Academy of Otolaryngology, and five by other medical organizations. These facts speak to a paucity of ethical discourse among surgeons. We chose to limit this pilot study to a single type of ethical issue, surrogate decision making, because we have observed substantial differences and vehemently held positions on this topic in our institution.
Our main objective was to elucidate the reasons for the surgery ethics gap. Several authors have speculated on causes of the gap, but no speculation was confirmed by this survey. Within the limits of our study, the high rate of response to the survey by surgeons suggests that they consider ethical deliberation to be as important as do other specialists, and that they are not alienated from ethical discourse. Surgeons may be no more paternalistic than others, because they chose authoritarian options no more often; in fact, pediatricians gave priority ranking to authoritarian options more often than did either surgeons or internists. The speculation that discussion of ethics may seem redundant to surgeons because ethical principles are deeply ingrained in surgeons through training and practice seems undermined by our finding that surgeons do not agree with each other on rating of options any more often than do other specialists. Thus, we are left with no clear explanation of the ethics gap in surgery.
Comparisons of the specialists for their ratings of legal acceptability of the options revealed an interesting finding. Pediatricians were less likely than either internists or surgeons to recognize the legal acceptability of discontinuing feeding the newborn at the parents’ request, and the acceptability of challenging the parents’ decision to discontinue feeding their daughter. Perhaps most surprising, however, was the finding that surgeons were the most likely, by a large margin, to believe that operating on the baby without parental consent was legally prudent. This observation may flag an important educational problem for all faculty, particularly surgeons.
The survey provides interesting insights into the way our general faculty understands ethical and legal issues in surrogate decision making. Surprisingly often, faculty members mistakenly rated as acceptable the ethically unacceptable and legally imprudent option to override the wishes of the parents in both cases. Indeed, this unacceptable option was ranked as the first choice of more than a quarter of the responding faculty. Finally, it is clear that using mental disability as a factor in clinical decision making is both ethically and legally unacceptable; yet, a third of our faculty would have changed their choices among the options if the newborn did not have Down syndrome. These observations may flag additional educational needs for all faculty members.
It was interesting, though perhaps not surprising, that senior faculty were more authoritarian in their choices than junior faculty. This may be a reflection of the trend in recent decades toward increasing recognition of the importance of patients’ exercise of autonomy in making clinical decisions. The training of older physicians took place before 1978, when physician authority over most clinical decisions was only beginning to wane. Younger physicians were trained in an era when patient autonomy had taken hold more securely in clinical decision making.
This pilot study has several shortcomings. The population we studied was small, and the 33% of our faculty who responded may not have been representative of the entire group. Moreover, the cases we presented narrowly focused on a single area of bioethics, decisions for incapacitated patients. Other areas of potential ethical conflict may have produced greater differences in choices by speciality groups. The precise form of the cases we presented and the questions we asked may have had some ambiguities, lending uncertainty to some responses. Finally, the study was a pilot, so the format was not designed to elicit the respondents’ reasoning underlying their choices, which might have helped to explain our findings better.
We suggest, however, that more detailed studies that avoid these shortcomings are needed, because it is incumbent on us to understand the reasons for the ethics gap. Surgeons have a strong sense of personal responsibility for patients’ welfare, and it is important that this ethic be transmitted to medical students and residents. This goal can be addressed in many ways, but one route certainly is to discuss and write about ethics more than we do. Moreover, our analysis of the legal aspects of the survey suggests that physicians have important lapses in their understanding of legal obligations. Perhaps more importantly, the results suggest that a significant gap may also exist between surgeons and other physicians in understanding health law.
References
This article has been cited by other articles:
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  J. W. Jones Reply Ann. Thorac. Surg., November 1, 2000; 70(5): 1758 - 1758. [Full Text] [PDF]
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